Forms

Claims

Claims

All Members

BlueCard Worldwide® International Claim Form:
Iowa South Dakota
Member Claim Form #C-5321 – Iowa  (122KB) Member Claim Form #C-3344 – South Dakota  (119KB)
Drug Card Prescription Claim Form (Blue RxSM or Blue Rx PreferredSM) #P-4303 – Iowa  (138KB) Drug Card Prescription Claim Form (Blue Rx or Blue Rx Preferred) #P-3320 – South Dakota  (106KB)
CMM Prescription Claim Form (drugs covered under health) #P-5344 – Iowa  (104KB)

CMM Prescription Claim Form (drugs covered under health) #P-3319 – South Dakota  (106KB)

Transplant Travel & LodgingReimbursement Form with Food #C-4603 - Iowa  (335KB)

Transplant Travel & LodgingReimbursement Form with Food #C-3625 - South Dakota  (232KB)
Transplant Travel & LodgingReimbursement Form without Food #C-4604 - Iowa  (228KB)

Transplant Travel & LodgingReimbursement Form without Food #C-3626 - South Dakota  (227KB)
PPO/CMM Vision Claim Form #C-53175 – Iowa  (165KB) Vision Claim Form #C-3352 – South Dakota  (128KB)

WHPI Vision Claim Form #C-9331 – Iowa  (163KB)
Blue DentalSM Claim Form #C-0365 – Iowa  (82KB)

 

Individual Health Plans (Coverage that Isn't Through an Employer)

Iowa South Dakota
Application for Short-Term Major Medical Policy #M-5733 – Iowa  (93KB) Application for Short-Term Major Medical Policy #M-3708 – South Dakota  (556KB)

Application for Individual Health, Dental & Life Insurance #N-53254 - Iowa  (323KB)  

Application for Individual Health & Life Insurance #M-3510 – South Dakota  (245KB)
Authorization for Automatic Account Withdrawal #M-5779 – Iowa  (245KB) Direct Pay Information Change Request Form #N-3704 – South Dakota  (122KB)
Tobacco Declaration Form #M-5749 – Iowa  (179KB) Authorization for Automatic Account Withdrawal #M-3506 – South Dakota  (408KB)

Individual Health Plan Contract Change Form #N-5428 1/11 – Iowa  (189KB) 

 State Sponsored Risk Pool – South Dakota

2011 Plan Option Election Form (Pool 4) #N-53281  (206KB) 

2011 Plan Option Election Form (Pool 5) #N-53282  (176KB) 

  

Medicare Supplement

Iowa South Dakota
Acknowledgement of Nonduplication-Medicare Supplement #M-5728 – Iowa 
 (243KB)

Application for MedicareBlue Supplement #M-3507 – South Dakota 10/11  (516KB)
Notice to Applicant Regarding Replacement of Medicare Supplement Insurance #M-53106 – Iowa 10/10  (156KB)

Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage #M-3503 – South Dakota  (534KB)
Authorization for Automatic Account Withdrawal #M-5779 – Iowa  (325KB)
Application for MedicareBlue Supplement #M-53314 10/11  (291KB)

Pharmacy

All Members
Drug Card Prescription Claim Form (Blue RxSM or Blue Rx PreferredSM) #P-4303 – Iowa  (103KB)
Formulary Exception
Exception Request Form - #P-23282  (106KB)
Iowa
Healthy and Well Kids in Iowa (hawk-i)
Member Initiated Exception Request Form for Non-Covered Pharmaceuticals #P-23282 – Iowa  (138KB)

Flexible Spending Accounts

All Members
Authorization Forms
Automatic Reimbursement Authorization Form #H-8340  (278KB)

Direct Deposit Authorization Form #G-8704  (250KB)

Individual Authorizing Disclosure - Iowa  (525KB)

Individual Authorizing Disclosure - South Dakota  (203KB)
Reimbursement Forms

2012 Medical Travel Expense Form #H-83109  (497KB)

2011 Medical Travel Expense Form 01/01/2011 thru 06/30/2011 #H-8397  (235KB)

2011 Medical Travel Expense Form 07/01/2011 thru 12/31/2011 #H-8399  (220KB)
Flexible Benefits Request for Reimbursement #H-8303
Flexible Benefits Request for Reimbursement (Spanish) #H-8371
Medical Necessity Form #H-8401  (216KB)
Orthodontic Payment Form #H-8402  (215KB)

Miscellaneous

 

 All Members
Iowa South Dakota
Appeal Form #C-53158 – Iowa  (59KB)
See also How to Appeal - Iowa  (19KB)

Appeal Form #C-3347 – South Dakota  (145KB)
See also How to Appeal - South Dakota  (20KB)

 

File an External Review – South Dakota Division of Insurance 

Authorization to Use or Disclose Protected Health Information #T-5605 – Iowa (262KB)
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself. See also Instructions for #T-5605  (7KB).

Authorization to Use or Disclose Protected Health Information #T-3601 – South Dakota  (34KB)
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself. See also Instructions for #T-3601  (7KB).
Personal Representative Appointment and Authorization to Release Protected Health Information #C-5674 – Iowa  (40KB)
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to relase protected health information to them. See also Instructions for #C-5674  (8KB).
 Personal Representative Appointment and Authorization to Release Protected Health Information #C-3617 – South Dakota  (36KB)
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to release protected health information to them. See also Instructions for #C-3617  (8KB).
Authorization for Disclosure to Housing Authority #T-4601 – Iowa  (221KB)
This form is used to authorize Wellmark to disclose premium information to a housing authority at the request of the individual.
 Authorization for Disclosure to Housing Authority #T-3609 – South Dakota  (215KB)
This form is used to authorize Wellmark to disclose premium information to a housing authority at the request of the individual.
Workers Compensation Questionnaire #C-5518 – Iowa  (87KB) Workers Compensation Questionnaire #C-3509 – South Dakota  (110KB)
Tyson Personal Representative Appointment and Authorization to Release Protected Health Information   (61KB)
 
 
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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
 
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